The contribution of digital health to net zero patient care in allergic diseases: From concept to practice
Authors: Jean Bousquet, Tari Haahtela, Josep M. Anto, Hanna Haveri, Francesca Puggioni, Mika Makela, Rodolphe Bourret, G. Walter Canonica
Journal: Allergy (2023)

There is growing awareness of the need to deliver cost-effective, high-quality, zero-carbon health care.1 The healthcare system needs to leverage developments in digital health to improve cost-effectiveness. This could contribute to reducing greenhouse gas (GHG) emissions, and represents a key strategy in the fight against the climate crisis. The term ‘digital health’ includes advanced medical technologies, disruptive innovations, and digital communication tools, all aiming to provide best practices. Choosing to be carbon-free—either mission driven or motivated by economics—has the potential to directly and indirectly impact the health and well-being of patients. Green innovation has become one of the most important approaches to achieving sustainable development in modern life.2 Environmental regulation largely impacts green technology innovation. Healthcare delivery has been recognized as a major area of opportunity for decarbonizing health care, an area where there is enormous potential to develop zero_carbon ‘digitally-enabled, patient-centred care’. The major sources of CHG emissions and environmental impacts on health care are those due to hospitals and medicines.3 As for any disease, ‘going green' includes (i) the improvement, design, or construction of healthcare facilities; (ii) daily operations such as cleaning, maintenance, and many clinical functions; and (iii) purchasing, food and transportation.2, 4 Becoming green in each of these areas can potentially improve health care, and directly and indirectly benefit patient health. Moreover, there are specific actions targeted at patients with allergic diseases, such as those related to the use of inhaled medication. Telemedicine can make health care greener.5 Although proposed for allergic diseases before the COVID-19 pandemic, telemedicine was shown to be effective in supporting clinical needs and in keeping patient/doctor relationships fruitful.6, 7 The contribution of digital care to decarbonize health care can be imbedded in the concept of planetary health. In 2015, the Rockefeller Foundation-Lancet Commission launched a novel approach called planetary health, and proposed a concept, a strategy, and an action plan. To safeguard human health in the Anthropocene epoch, human health and the health of the Planet should go together.8 A conference entitled ‘Europe That Protects: Safeguarding Our Planet, Safeguarding Our Health’ was based on the concept of planetary health. This event was co-organized in 2019 by the Finnish Institute for Health and Welfare, the Finnish Environment Institute, and the European Commission (Directorate General Research and Development) under the auspices of Finland's Presidency of the European Union.9, 10 It brought together stakeholders—including researchers, policy makers, and regulators—to identify and discuss: (i) the scientific challenges involved in harvesting and enhancing the benefits of a sound environment for human health, and (ii) the challenges in overcoming environmental threats to human health. The main outcomes consisted of recommendations on research and innovation priorities for the EU and Member States in order to enable collaborative work to protect both human health and our planet. The best strategies for planetary health would be those that co-benefit both the health of the Planet and human health, in sharp contrast to actions that co-harm both humans and the Planet (Figure 1). Other activities can have the opposite impacts to those that benefit human health, at the expense of causing harm to the Planet. The planetary health approach to health care involves the need to understand that any health care that harms the Earth's natural systems will ultimately be negative for human health. The Finnish Allergy Programme (FAP), a Good Practice of DG Health and Food Safety (EU), was developed from 2008 to 2018 with the aim of reducing the burden of allergic diseases.11 A hallmark of the programme was the emphasis on tolerance and resilience (instead of the traditional concepts) as a way to promote health preservation and prevent the medicalization of mild symptoms. Importantly, the FAP included improving contact with nature as one of its principles, becoming a precursor of the planetary health approach to allergic diseases (Table 1). The FAP collaborated with MASK (Mobile Airways Sentinel networK) in the development of a digital tool to impact planetary health. In 2015, MASK-air® (Mobile Airways Sentinel networK for rhinitis and asthma) was launched as a project of the European Innovation Partnership on Active and Healthy Ageing (EIP-on-AHA, DG Santé and DG CONNECT).12 It is a Good Practice of DG Santé (the Directorate-General for Health and Food Safety) on digitally-enabled, patient-centred care pathways. It represents an example of the digital cross-border exchange of real-world data and experience, with the aim of improving patient-centred care13 (Table 2). As a side event of the meeting in Finland, a symposium—organized as the final POLLAR (Impact of air POLLution on Asthma and Rhinitis, EIT Health) meeting14, 15—explored the digital transformation of health and care to sustain planetary health in airway diseases.16 The integration of information technology tools for climate, weather, air pollution, and aerobiology in MASK was considered to have the potential to inform patients on environmental threats as well as on the impact of health care for allergy on the Earth's natural systems. The latter is illustrated by the use of pressurized metered-dose inhalers (MDIs), which have a much higher carbon footprint than dry powder inhalers (DPIs).17 Integrating digital inhalers or mHealth apps into the clinical care of patients with asthma and chronic obstructive pulmonary disease is likely to reduce the need for the unnecessary extra use of reliever medications.18 Plant species vary under different climate conditions, and a warning system is being developed in CATALYSE. The distribution of pollen in the air and its trends can be used to assess the impact of climate change on public health. MASK-air® was launched to develop an early warning system to inform patients about the beginning of the pollen season.19 SILAM (System for Integrated modeLling of Atmospheric composition) is a global-to-mesoscale dispersion model that has been developed by the Finnish Meteorological Institute (FMI).20 It provides quantitative information on the atmospheric pollution of anthropogenic and natural origin, particularly allergenic pollen concentrations. POLLAR has combined MASK-air clinical data with SILAM forecasts. A new Horizon Europe grant, CATALYSE (Climate Action to Advance HeaLthY Societies in Europe; grant agreement number 101057131), which started in September 2022, aims at better understanding climate change and defining ways to counteract it. One of the objectives of this project is to develop early warning systems and predictive models to improve the effectiveness of adaptation strategies to climate change. One of the early warning systems to be developed is focused on allergic rhinitis (CATALYSE Task 3.2). It stems from a collaboration between the FMI (Finland), Porto University (Portugal), MASK-air SAS (France), ISGlobal (Spain), Hertie School (Germany), and the University of Zurich (Switzerland). It is to be implemented with the support of EAACI. The potential of MASK as an early warning system of climate change for allergic patients will be tested in Lahti, the capital of the region of Päijänne Tavastia (Päijät-Häme), one of the main economic hubs of Finland. Lahti's journey towards becoming a forerunner in environmental issues began with the restoration of Lake Vesijärvi in the late 1970s and early 1980s. Since then, Lahti has been among the first to participate in many environment-related projects over the years. It was therefore natural for Lahti to become the first city in Finland to win the European Green Capital Award in 2021 (https://www.lahti.fi/en/blog/lahti-home-of-planetary-health-and-lifestyle-medicine/). The latest effort, Nature Step to Health—Lahti Regional Health and Environment Programme 2022–2032, combines public health promotion with stopping nature loss and mitigating climate change in the spirit of planetary health (https://www.lahti.fi/en/blog/lahti-home-of-planetary-health-and-lifestyle-medicine/). The indicator diseases for the Programme are asthma, diabetes, obesity, and depression. The practical actions require that all citizens favour a healthy diet, increase physical activity and mobility, improve the housing environment, and encourage contacts with nature. The regional health and wellbeing authorities are implementing the Programme together with the City of Lahti and Lahti University Campus.21 Real-world data are being used from official registers, and questionnaire surveys are being carried out. Cross-sectional research, new services, and nature-based solutions for environmental sustainability are being promoted. Jean Bousquet and G. Walter Canonica proposed the topic and provided the outline of the paper. Jean Bousquet wrote the paper. Tari Haahtela and Josep M. Anto were part of the think tank process and provided their help for the paper. Hanna Haveri, Mika Makela, Francesca Puggioni and Rodolphe Bourret provided their expertise for the paper. The authors thank Ms. Anna Bedbrook for the English revision of the paper. TH reports lecturing fee from Orion Pharma. None declared. Data sharing is not applicable to this article as no new data were created or analyzed in this study.